Maxillofacial Injuries in Sports 24

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A. Bernaerts, MD

Department of Radiology, Sint-Augustinus Hospital, Ooster- veldlaan 24, 2610 Wilrijk, Belgium

P. Ehlinger, MD

Department of Oral and Maxillofacial Surgery, Sint- Augustinus Hospital, Oosterveldlaan 24, 2610 Wilrijk, Belgium

K. Chapelle, MD

Department of Oral and Maxillofacial Surgery, Sint-Maarten Hospital, Rooienberg 25, 2570 Duffel, Belgium

Maxillofacial Injuries in Sports 24

Anja Bernaerts, Philippe Ehlinger, and Karen Chapelle

24.1 Introduction

Trauma due to sports can have a signiﬁ cant impact on unprotected sites of the body such as the maxil- lofacial region. The commonest sports related maxil- lofacial injuries are soft tissue lacerations followed by

dentoalveolar fractures and minor facial bone frac- tures (Hill et al. 1998; Tuli et al. 2002). The most frequently recorded maxillofacial bone fractures involve the mandible, the zygomatic and nasal bone (Maladiere et al. 2001).

According to different reports, sports-related facial fractures account for 4%–18% of all sports injuries and 6%–33% of all facial bone fractures (Bayliss and Bedi 1996; Carroll et al. 1995; Mourouzis and Koumoura 2005). This variation in occurrence may reﬂ ect the geographic differences in the level of par- ticipation in sports activities and the type of popular sports. Which sport is responsible for the majority of injuries varies above all according to the popularity that each sporting activity has in a particular coun- try (Cerulli et al. 2002; Flanders and Bhat 1995;

Lim et al. 1993; Tanaka et al. 1996). The majority of facial fractures in Western countries today occur during team sports, such as soccer, basketball and rugby (Cerulli et al. 2002; Maladiere et al. 2001;

Mourouzis and Koumoura 2005). Fractures of the maxillofacial region are more frequent in males and between the ages of 20 and 30 years, most likely reﬂ ecting the high levels of physical activity in this sex and age group (Mourouzis and Koumoura 2005). Sports are also a primary cause of maxillofa- cial fractures in the paediatric population, probably because of the learning stages of sports ability and the ignorance of the consequences of taking greater risks (Gassner et al. 2004). A recent study has shown that 26% of paediatric facial fractures were caused by bicycle accidents (Iida and Matsuya 2002).

Various sports committees have adopted speciﬁ c guidelines for the prevention of dental and cranio- maxillofacial injuries. Sports such as hockey and American football have adopted full facial and cra- nial protective headgear. Evolution of these protec- tive devices has signiﬁ cantly reduced many types of head and neck injuries in these sports (Greenberg and Haug 2005). Nevertheless, there are an increas- ing number of people who are engaged in sporting activities and new, high-velocity vehicular and high

C O N T E N T S

24.1 Introduction 401

24.2 Correlation Between Injury Type and Injury Mechanism Among Sports 402 24.2.1 Dentoalveolar Fractures 403

24.2.2 Facial Bone Fractures 403

24.3 Imaging Strategy 404 24.3.1 Plain Radiography 404 24.3.2 Computed Tomography 406 24.3.3 Magnetic Resonance Imaging 407

24.4 Speciﬁ c Sports-Related Maxillofacial Injuries 408

24.4.1 Soft-Tissue Injuries 404 24.4.2 Dentoalveolar Injuries 408 24.4.3 Mandibular Fractures 408 24.4.4 Central Midface Fractures 409 24.4.5 Lateral Midface Fractures 410 24.4.6 Frontal Sinus Fractures 412 24.5 Conclusions 412

Things to Remember 412 References 413

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altitude activities are introduced. Moreover, amateur athletes often do not use any protective clothing or equipment in sports in which the use of protective gear is recommended.

24.2 Correlation Between Injury Type and Injury Mechanism Among Sports

There have been few studies that have been directed toward the biomechanics of maxillofacial injuries asso- ciated with sports. Perhaps the difﬁ culty of engaging in such a study is the large variety of sports activities that are available today, ranging from those with minimal interpersonal contact to those with high-energy con- tact. In addition, comparative analysis of these studies is hampered by varied selection criteria and the use of retrospective non-consecutive data.

24.2.1 Dentoalveolar Fractures

In dentoalveolar fractures, a high-velocity trauma, such as a baseball that takes a bad hop and strikes

Box 24.3. Computed tomography (CT) with 2D and 3D reformations

● High accuracy

● Midface trauma

● Complex fractures

●

Multiplicity of fragments

●

Degree of dislocation and rotation

●

Skull base involvement

●

Cribriform plate, lacrimal duct, optic canal, superior orbital ﬁ ssure or infraorbital canal involvement

● Further characterization and classiﬁ cation of solitary fractures

● Posttraumatic osteomyelitis Box 24.2. Conventional radiographs

(Waters view; Caldwell view; lateral view and submentovertex view)

● Difﬁ cult interpretation

● Solitary, low-impact, fractures

● Nasal trauma

Box 24.1. Panoramic radiograph

● Easy interpretation

● Isolated trauma of the mandibula

●

Dentoalveolar injuries

●

Mandibular fractures

● Screening in all patients with maxillofacial fracture

the maxillary incisors, is more likely to cause a tooth fracture, whereas a low velocity trauma is expected to cause a displacement injury (e.g., an avulsion).

Children with a type 2 malocclusion (so-called ret- rognathism or overbite) in particular will be prone to sports-related dentoalveolar injuries of the upper incisors.

Another mechanism, indirect trauma, occurs when the mandible whiplashes into collision with the max- illa. This trauma can occur from a blow to the chin, such as an uppercut in boxing, a football tackle, or a hockey stick. The concussion is capable of shattering posterior teeth.

Enamel infraction can be caused by acute or chronic trauma such as grinding or clenching (e.g., weightlifting) (Kurtz et al. 2005).

24.2.2 Facial Bone Fractures

Sporting activities can be grouped into differ- ent categories in order to understand better the injury mechanism in sports related facial bone fractures:

•

Team sports: soccer, rugby, basketball, football, handball

•

Vehicular sports: bicycling, mountainbiking,

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horse-riding, skiing, snowboarding, ice-hockey, in-line skating

•

Sports with small balls: tennis, baseball, cricket, golf

•

Combat sports: boxing, karate, Kung-fu, wres- tling

•

Individual sports: swimming, diving, gymnastics, body-building etc.

In team sports the main type of impact in facial bone fractures appears to be a collision with another player that takes place mainly when the ball is played with the forehead. At this instant there can be an elbow-head impact or a head-head impact. An analy- sis of the anatomic distribution of facial fractures sus- tained during team sports showed that the mandible, followed by the zygomatic region, is most commonly affected (Maladiere et al. 2001; Mourouzis and Koumoura 2005). Football players do not encounter orofacial injuries as often as other athletes because faceguards and mouth protectors are now mandatory (Flanders and Bhat 1995; Sane 1988). This might also explain the relative low incidence of facial inju-

ries reported in contact sports such as boxing (Hill et al. 1998).

In vehicular, non-car, sports, a fall to the ground is the most commonly reported type of impact. Frac- tures of the mandible and zygoma are most prominent in vehicular sports as well, but, unlike team sports, the frontal sinus and central midface are commonly affected too (Gassner et al. 1999a; Maladiere et al.

2001). Generally, mountainbikers sustain more severe maxillofacial injuries in comparison with bicyclists.

The dominant fracture site in bicyclists is the zygoma, whereas mountainbikers encounter more serious midface fractures such as Le Fort I, II, and III frac- tures (Gassner et al. 1999b). In horse-riding, being kicked by the horse is correlated with more severe injuries (Fig. 24.1) (Ueeck et al. 2004).

Box 24.4. Magnetic resonance (MR) imaging

● Cranial nerve palsy

●

Nerve compression due to haematoma

●

Nerve transsection

●

Axonal injury

● Traumatic damage to the temporomandibular joint disc

● Brain concussion

● Posttraumatic meningocele

● Posttraumatic meningitis

●

Inﬂ ammatory collections

●

Abscess formation

● Posttraumatic ischemic necrosis of the condy- lar head of the mandible

Fig. 24.1a–c. Horsewoman with a complex maxillofacial injury after being kicked in the face. A clinical photograph immedi- ately following injury shows severe soft-tissue lacerations (a).

A postoperative panoramic radiograph (b) and Waters view (c) after reduction and internal ﬁ xation demonstrate the involvement of the mandible, maxilla, nose and zygoma. [Reprinted with permission from Raghoebar et al. (2005)]

b

c a

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A missile type of injury to the head caused by the ball or other implement is most mentioned in sports with small balls such as baseball (Bak and Doerr 2004;

Delilbasi et al. 2004; Maladiere et al. 2001). Con- tact with the racquet, the bat or club also is a common cause of injury in this category (Lim et al. 1993).

Sport diving carries inherent risk to the maxillo- facial region in its own way. Atypical facial pain and temporomandibular joint dysfunction may result from repeated use of the mouthpiece of the regulator.

The mechanical effects from changes in ambient pres- sure may cause paranasal sinus barotraumas, cranial nerve injury, and barodontalgia (Brandt 2004).

24.3 Imaging Strategy

The diagnosis of facial fractures is usually accom- plished by a combination of clinical and imaging examinations. Often, deformity of the facial skeleton is initially concealed by overlying edema, haemor- rhage, and soft tissue injury. Therefore, the clinician is primarily concerned with the detection of maloc- clusion, abnormal mobility, and crepitation as signs of fractures. Any evidence of a palpable step-off at the orbital rim, diplopia, hypertelorism, midfacial elon- gation, cerebrospinal fl uid rhinorrhea, or fl attening of the cheek further helps the clinician identify the type of fracture present. However, only after imaging studies can the fracture be completely identifi ed and characterized (Greenberg and Haug 2005).

24.3.1 Plain Radiography

The panoramic radiograph is still a highly cost-effec- tive and accurate method for the determination of the presence of mandibular and dentoalveolar fractures (Fig. 24.2). In addition, it is used as an initial survey fi lm in all maxillofacial fractures to spot associated lesions such as dentoalveolar fractures or infl amma- tory lesions of the jaws which could complicate the postoperative course (Box 24.1). In case of dental trauma, supplementary intraoral periapical fi lms always are required to obtain adequate image detail (Fig. 24.3) (White and Pharoah 2000).

When trauma of the viscerocranium occurs as an isolated injury due to a blow or fall, like in sports injuries, it can be investigated by conventional radio- graphs ﬁ rst. A basic facial series consists of three or four ﬁ lms: a Waters view (PA view with cephalad angulation), a Caldwell view (PA view), a lateral view, and occasionally a submentovertex view (Fig. 24.4b–

e). A Waters view allows recognition of interruption of the zygomaticoalveolar arch and of the orbital fl oor and lateral wall, while a Caldwell view permits delineation of the lamina papyracea, zygomatico- frontal suture, fl oor of the nasal cavity and maxil- lary sinus. Delineation of zygomatic arch fractures is best performed by a submento-vertex view. Nasal and anterior nasal spine fractures and posterior dis- placement of the midface are recognized on a lateral fi lm. A focussed lateral, Waters and superior-inferior view may be requested for documentation of a nasal fracture (Fig. 24.5a) (Box 24.2) (Schuknecht and Graetz 2005; Som and Brandwein 2003).

Fig. 24.2. Panoramic radiograph demonstrating an oblique fracture of the left mandibular body and an extracapsular fracture of the right condylar process (arrowheads)

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Fig. 24.3. Periapical radiograph shows a transverse root fracture of the left primary central maxillary incisor with some distraction of the fragments (arrowheads)

Fig. 24.4a–e. Three-dimensional (3D) surface shaded CT reconstruction (a) of a trimalar (zygomatic) fracture in a young male soccer player after being struck in the face by an opponent’s knee. Radiographic evaluation after osteosynthesis includes a Waters view (b), a Caldwell view (c), a lateral (d) and submento-vertex view (e). The latter view best delineates the zygomatic arch (arrowheads)

a c

e b

d

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24.3.2 Computed Tomography

The traditional strong role of conventional images in patients with facial bone fractures, however, is cur- rently decreasing. Spiral multislice computed tomog- raphy (CT) is progressively replacing the panoramic radiograph and conventional radiographs for maxil- lofacial trauma, and is increasingly being performed in addition to conventional ﬁ lms to detail and classify trauma to the mandible as well. Metal artefacts from tooth ﬁ llings however may degrade bone visualisation.

CT is the imaging technique of choice to display the multiplicity of fragments, the degree of dislocation and rotation, or skull base involvement (Fig. 24.5b,c).

CT is also particularly important to recognize poten-

tial, cribriform plate, lacrimal duct, optic canal (optic nerve), superior orbital ﬁ ssure (cranial nerve III–VI) or infraorbital canal (infraorbital nerve) involvement.

Maxillofacial trauma with suspicion of osseous involve- ment requires thin collimation of slices (0.75–1 mm) to detail the location and course of fracture lines. The data set provides high-resolution two-dimensional (2D) multiplanar reconstructions (MPR) with contiguous 2-mm slices in the axial and coronal plane displayed in high resolution bone window (window width, 3200 HU;

center level, 700) and in soft tissue settings (window width, 300 HU; center level, 100). Additional sagittal reconstructions are reserved for central midface and mandibular condylar fractures. Three-dimensional (3D) surface shaded CT reconstructions add the third dimension at one glance and are particularly help-

Fig. 24.5a–c. A 25-year-old male soccer player who sustained a complex nasal fracture after being kicked in the face by an opponent’s foot. Radiographic evaluation of the nasal bone including a frontal, superior-inferior and lateral view (a) conﬁ rms a fracture of the nasal bone (white arrows). A deviation of the cartilaginous portion of the nasal septum is noted (black arrow).

Axial CT scans viewed at “bone” (b) and “soft-tissue” (c) window settings show comminuted fractures of both nasal bones and right frontal process of the maxilla (white arrows). Also note the presence of a septal haematoma (black arrow) and an associ- ated displaced fracture at the right zygomaticosphenoid suture

a

c b

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ful for treatment in case of multiple fragments and/

or severe fragment dislocation (Fig. 24.4a) (Box 24.3) (Reuben et al. 2005; Schuknecht and Graetz 2005;

Som and Brandwein 2003; Turner et al. 2004).

24.3.3 Magnetic Resonance Imaging

Magnetic resonance (MR) imaging does not visual- ize the bone directly and therefore small yet unsta- ble nondisplaced facial fractures may not be seen.

Nevertheless, supplementary MR examinations are required when cranial nerve palsy occurs in order to recognize neural compression. MR imaging is more sensitive to detect nerve compression due to haema- toma, nerve transsection, or axonal injury. MR imag- ing also is the most sensitive technique to evaluate traumatic damage to the temporomandibular joint disc (Fig. 24.6) (Box 24.4).

Early and late complications of trauma related to the orbit, anterior cranial fossa, or lateral skull base due to infection, brain concussion, or her- niation require CT to visualize the osseous pre- requisites of complications, and MR to define the adjacent brain and soft tissue involvement. MR is more sensitive to display dural defects, recognize inflammatory collections following meningitis, or distinguish brain concussion from abscess forma- tion. In patients with suspicion of posttraumatic osteomyelitis, CT is superior to MR, as it pro- vides additional information with respect to a likely incomplete stability of the osteosynthesis, the degree of callus formation, or the presence of sequestra as sequela of osteomyelitis. MR imaging, however, is more sensitive to detect early osteomy- elitis or ischemic necrosis of the condylar head of the mandible (Reuben et al. 2005; Schuknecht and Graetz 2005; Som and Brandwein 2003;

Turner et al. 2004).

Fig. 24.6a–d. Posttraumatic disk adhesion demonstrated by T1-weighted MR images. Closed-mouth image (a) shows a normal position of the disk (white arrowhead) and the condyle (black arrowhead) relative to the glenoid fossa. Upon opening of the mouth (b–d), the condyle moves inferior to the articular eminence; however the disk (white arrowhead) remains stuck in the glenoid fossa. Courtesy of Dr. J. Casselman

c d

a b

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24.4 Speciﬁ c Sports-Related Maxillofacial Injuries

24.4.1 Soft-Tissue Injuries

Soft-tissue injuries are by far the most common max- illofacial injuries associated with sports (Hill et al.

1998). Soft-tissue injuries may be classiﬁ ed as abra- sions, lacerations, cuts, haematomas and burns.

Ocular soft tissue injuries also are frequently seen in sports related trauma, mainly in racquet sports (squash, tennis, and badminton) and soccer (Barr et al. 2000). Problems such as hyphema (bleeding in the anterior chamber), retinal tears, lens dislocation, penetrating globe injury, optic nerve compression, superior orbital ﬁ ssure syndrome (cranial nerve III to VI paralysis) and retrobulbar hematoma should be cautiously thought about (Greenberg and Haug 2005).

Radiologic examination should be carefully con- sidered in each patient to spot underlying fractures.

24.4.2 Dentoalveolar Injuries

Dental injuries range from minor enamel fragments, to complete crown-root fractures, or complete tooth avulsion. When the dental fracture involves the alveo- lar bone, whether in the maxilla or the mandible, these injuries are classiﬁ ed as dentoalveolar fractures.

These types of injuries are common in sports and are highly preventable with the use of mouthguards (Greenberg and Haug 2005). Children have a dis- advantage with regard to dentition. When the tooth germ lies in the fracture, the tooth can fall during healing or have delayed development and deformity that does not manifest clinically until the permanent tooth erupts (Som and Brandwein 2003).

Crown fractures are very common. They can involve only the enamel (infraction) or can in addi- tion involve the dentine (uncomplicated fracture) and pulp (complicated fracture) (Fig. 24.7). Dental root fractures (Fig. 24.3) and crown-root fractures are less common. The term “concussion” indicates a crushing injury to the vascular structures at the tooth apex and to the periodontal ligament, resulting in inﬂ ammatory edema. The radiographic appearance of a dental concussion is widening of the periodontal

ligament space (radiolucency between the cementum of the root and the lamina dura of the bony socket).

Luxation of teeth is dislocation of the articula- tion (represented by the periodontal ligament) of the tooth. Traumatic forces, depending on their nature and orientation, can cause intrusive luxa- tion (displacement of teeth into the alveolar bone), extrusive luxation (partial displacement of teeth out of the sockets), or lateral displacement (movement of teeth other than axial displacement). In intrusive and lateral luxation, comminution or fracture of the supporting alveolar bone accompanies dislocation of the tooth. Radiographic examination of luxated teeth may demonstrate the direction of the displacement by the widening and/or obliteration of the periodon- tal ligament space and shows associated fractures of the alveolar bone (Fig. 24.8).

Avulsion is the complete displacement of the tooth from its socket. The maxillary incisors are the most frequently avulsed teeth. Avulsion is not an uncom- mon occurrence in sports (Kurtz et al. 2005; White and Pharoah 2000).

24.4.3 Mandibular Fractures

There is a variety of causes for mandibular fractures predominated by assaults and motor vehicle colli- sions, with sports as a smaller aetiology (2%–6%) (Greenberg and Haug 2005). However, according to the investigations of Emshoff et al. (1997) sports are increasingly implicated in the causes of mandibular fractures. His study showed sporting activities to be

Fig. 24.7. Spot view of a panoramic radiograph demonstrat- ing a crown fracture of the right lateral maxillary incisor (tooth 12)

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the main causative factor of mandibular fractures, accounting for 31.5%. The difference may be attrib- utable to the extensive sports facilities and tourism industry in the studied region (Innsbruck).

Mandibular fractures can be categorized based on anatomic location: (para)-symphyseal, body, angle, and ascending ramus (Figs. 24.2 and 24.8). Fractures affecting the ramus mandibulae are subdivided into those directed to the coronoid or condylar process.

Condylar fractures may be intracapsular or extracap- sular in location. In extracapsular fractures, the frac- ture line is below the insertion of the lateral pterygoid muscle. Displacement is usually in an anteromedial direction (Schuknecht and Graetz 2005). In sports- related mandibular fractures, the subcondylar region is most commonly affected (Emshoff et al. 1997).

24.4.4 Central Midface Fractures

Central midface fractures are classiﬁ ed into fractures of the nose and nasoethmoid complex, isolated max- illary fractures and Le Fort I, II and III types of frac- tures, (Som and Brandwein 2003).

Nasal fractures are the most common sports related facial fractures with sports accounting for up to 27% of all nasal fractures (Greenberg and Haug 2005). There is, however, a large discrepancy of preva- lence amongst papers. Nose fractures can be treated by other specialities (ENT and plastic surgeons) than maxillofacial surgeons in some hospitals and therefore might be underestimated in some studies (Frenguelli et al. 1991; Maladiere et al. 2001). The majority of nasal bone fractures involve the thinner, distal third of the nasal bones. A lateral blow to the nose usually causes a simple cartilage depression or fracture of only the ipsilateral nasal bone. On the other hand, a frontal nasal blow usually fractures both nasal bones at their lower ends, and the septum is also dis- placed and fractured. With a greater force, the entire nasal pyramid, including the frontal processes of the maxillae, may become detached (Fig. 24.5) (Som and Brandwein 2003).

Nasoethmoid fractures are most often caused by a blow over the bridge of the nose resulting in pos- terior displacement of the nasal bone and frontal process of the maxilla with telescope-like deforma- tion and foreshortening of the anterior ethmoid. The lacrimal bone and cribriform plate are frequently involved (Schuknecht and Graetz 2005; Som and Brandwein 2003).

Isolated maxillary fractures, other than alveolar fractures, can result from a blow directly over the anterior maxillary wall. The fractures involve the anterior and lateral antral walls and extend toward the pyramid aperture and down into the maxillary alveolus (Fig. 24.9) (Som and Brandwein 2003).

Complex midface fractures are typically referred to in the context of Le Fort’s early anatomic studies.

Although visualization of injury to the struts and buttresses of the face is required for repair of these fractures with restoration of the 3D stability and symmetry of the face, the Le Fort classiﬁ cation still appears to be a succinct way of summarizing and communicating the major planes of certain fractures.

The greatest frequency of Le Fort types of fractures results from assaults and motor-vehicle collisions, with sports accounting for 5%–8% of such fractures (Greenberg and Haug 2005).

Common to all Le Fort fractures is fracture of the pterygoid processes. In addition, each Le Fort frac- ture has a unique component (Fig. 24.10) (Rhea and Novelline 2005). The Le Fort I fracture runs hori- zontally above maxillary alveolar process and is the only one that involves the anterolateral margin of the nasal fossa just above the maxillary alveolar process.

Fig. 24.8. Oblique view of the mandible dem- onstrating a vertical fracture of the mandibular body. There is a concomitant extrusive luxation of the right canine. Note the widening of the periodontal ligament space that is accentuated at the apical region (white arrow)

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The Le Fort II fracture is pyramidal in shape with teeth at base of pyramid and nasofrontal suture at apex of pyramid. This type of fracture is the only one that involves the inferior orbital rim. Posterior and lateral walls of maxillary sinus are broken (Fig. 24.11).

The Le Fort III fracture separates bones of face from the rest of the skull. The fracture crosses the naso- maxillary suture, the lamina papyracea medially, and the superior orbital ﬁ ssure and courses laterally to involve the sphenozygomatic and frontozygomatic suture. The Le Fort III fracture is the only one that involves the zygomatic arch.

Fig. 24.9. Axial CT scan in bone window setting of an iso- lated maxillary fracture involving the left anterior antral wall (arrow) in a 19-year-old woman after falling from her bicycle.

Note the presence of a haemorrhage within the right antrum with an air-ﬂ uid level

24.4.5 Lateral Midface Fractures

Lateral midface fractures consist of zygomatic frac- tures (trimalar, or tripod), zygomatic arch fractures, zygomaticomaxillary fractures, zygomaticomandib- ular fractures and fractures of the ﬂ oor of the orbit (blow-out fractures) (Som and Brandwein 2003).

Sports injuries account for 4%–11% of all zygomatic fractures (Greenberg and Haug 2005).

In a so-called trimalar or tripod fracture, the frac- ture line extends from the lateral orbital wall (zygo- maticofrontal suture and the zygomaticosphenoid suture) to the inferior orbital fi ssure, then across the orbital fl oor near the orbital canal, down the anterior maxilla near the zygomaticomaxillary suture, and up the posterior maxillary wall back to the inferior orbital fi ssure. There is also a fracture through the weakest part of the zygomatic arch, which is about 1.5 cm dorsal to the zygomaticotemporal suture (Figs. 24.4 and 24.12).

When there is an isolated fracture of the zygomatic arch, there are usually at least three discrete fracture lines, creating two fracture segments. These pieces are displaced medially and downwards, reﬂ ecting the direction of the impact force (Fig. 24.13).

Zygomaticomaxillary fractures differ from trima- lar fractures in that the former fractures involve the

Fig. 24.10. Drawing in frontal projection showing Le Fort I, II, and III types of fractures. [Modiﬁ ed from Rhea and Novelline (2005)]

Le Fort

Fig. 24.11. Three-dimensional (3D) surface shaded CT recon- struction of a left hemi-Le Fort II fracture caused by a skiing accident (black arrow). This type of Le Fort fracture is the only one that involves the orbital rim

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orbital ﬂ oor, extend down the anterior maxilla (often more medially than in a typical trimalar fracture), run to the premolar region, and then extend across the palate to the maxillary tuberosity and lower pter- ygoid plates.

Zygomaticomandibular fractures differ from zygomatic fractures only by the additional fracture of the mandibular condyle, coronoid process, or both (Som and Brandwein 2003).

One-third of orbital blow-out fractures are sus- tained during sports. Soccer is most commonly involved (Jones 1994). A blow to the orbit by an object that is too large to enter the orbit (baseball, fi st, etc.) may cause a blow-out fracture resulting in fracture of the orbital fl oor and – by defi nition – leaving the inferior orbital rim intact. Herniation of orbital fat, inferior rectus muscle and inferior oblique muscle can occur (Fig. 24.14). Additionally, or rarely alter- natively, the medial orbital wall may be displaced into the ethmoid resulting in the so-called “medial blow-out fracture” with potential herniation of the medial rectus muscle. Supraorbital roof fractures are uncommon (Schuknecht and Graetz 2005; Som and Brandwein 2003).

a

Fig. 24.12a–c. Axial CT images through the orbit (a), the zygo- matic arch (b), and the maxilla (c) show a left trimalar fracture sustained during a bicycling accident due to a fall. The left frontosphenoid fracture is minimally displaced (arrow in a).

The zygomatic arch is also fractured in two places (arrows in b). The most caudal image shows the complex fracture near the zygomaticomaxillary suture (arrow in c) with involvement of the orbital ﬂ oor, the orbital canal, and anterior and posterior maxillary wall. There is orbital and subcutaneous emphy- sema, and haemorrhage is present in the left antrum. Also note the presence of a prolapsed fracture segment in the antrum c

b

Fig. 24.13. Spot view of a submentovertical view shows a depressed fracture of the left zygomatic arch sustained during an elbow-head impact in a soccer game. [Reprinted with permission from Raghoebar et al. (2005)]

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24.4.6 Frontal Sinus Fractures

Frontal fractures are less common than other frac- tures of the craniomaxillofacial skeleton because of their greater thickness and biomechanical advan- tages. Sports injuries account for 3%–5% of all frac- tures (Greenberg and Haug 2005).

Frontal bone fractures are classiﬁ ed according to the involvement of the supraorbital rim, anterior wall, posterior wall, or sinus ﬂ oor (Fig. 24.15) (Som and Brandwein 2003).

24.5 Conclusions

In conclusion, the majority of sports-related cranio- maxillofacial injuries are of a minor nature including soft tissue lacerations followed by dentoalveolar frac- tures and minor facial bone fractures. The most fre- quently recorded maxillofacial bone fractures involve the mandible, the zygomatic and nasal bone and occur during team sports, such as soccer and rugby, as a consequence of an impact against another player.

Dentoalveolar fractures always require intraoral peri- apical ﬁ lms to obtain adequate image detail. CT is the modality of choice for the most complete evaluation of the facial skeleton and facial soft tissues.

Fig. 24.14a,b. A Waters view (a) and coronal CT image (b) of a blow out fracture. A completely displaced piece of bone, a trap- door fracture (arrow), can be identiﬁ ed as can the typical “teardrop” herniation of orbital contents

a b

Things to Remember

1. The majority of sports-related craniomaxillo- facial injuries are of a minor nature including soft tissue lacerations followed by dentoalveo- lar fractures and minor facial bone fractures respectively.

2. The most frequently recorded facial fractures in sports include nasal, mandibular, and zygo- matic fractures.

3. The majority of facial fractures occur during team sports, such as soccer and rugby, and as a consequence of an impact against another player.

4. In vehicular sports, a fall to the ground is the most commonly reported type of impact and the frontal sinus and central midface are com- monly affected.

5. Dentoalveolar fractures always require intra-

oral periapical ﬁ lms to obtain adequate image

detail. CT is the modality of choice for the

most complete evaluation of the facial skel-

eton and facial soft tissues.

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Fig. 24.15a–d. Young male soccer player who sustained a frontal sinus fracture in a heading duel. A preoperative axial CT scan (a) shows a depressed comminuted fracture of both the anterior and posterior frontal sinus tables. Peroperative photographs before (b) and after (c) repositioning and osteosynthesis show the impact site. Postoperative lateral view (d) shows an anatomic alignment of the fracture frag- ments. [Reprinted with permission from Raghoebar et al. (2005)]

a

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